How To Get A Clinical Gap Exception

I just wanted to create a guide to getting a clinical gap exception, because I think that it would be helpful to others in my position.

So let's say your doctor has told you that you need a specialized surgery, such as a vestibulectomy. The problem is, you only have in-network insurance, and no in-network doctor can perform such a highly specialized surgery.

What you need to aim for is something called a clinical gap exception. If granted, this means your insurance is willing to treat your procedure as in-network (and hopefully pay for it at the in-network rate). Here's how you do it.

1. Ask your doctor (in my case, Dr. Goldstein) to write you a Letter of Necessity. The Letter of Necessity will explain what non-invasive treatments you have already tried and how they have failed. It will also explain exactly what the procedure that you want to have entails.

2. Set up your appointment for your vestibulectomy (or other surgery). You need to make sure it is set up so that you have the date, time, name of doctor operating, name of hospital where you are being operated upon, etc, all coordinated. If you are going to Dr. Goldstein, Ruth will help you coordinate this.

3. Make an appointment with your primary care physician or gynecologist. They are the ones who will need to call your insurance company and talk about why you need a clinical gap exception. You cannot do it on your own. You can make this appointment with your primary care physician part of your normal physical, or make it something separate. Just make sure to do it in person.

4. Give your primary care physician a copy of the Letter of Necessity outlining why you need to have this procedure. Also explain it to her verbally. Then give her a step-by-step checklist of what exactly she needs to do to set up the clinical gap exception. The checklist should look like this:

a) Here is the contact information and phone number of my specialist (in my case, Dr. Andrew Goldstein), who will also be the person who is operating on me. Feel free to call him if you have any further questions about my case. Here is the best phone number to reach him, and if you can't reach him, to reach x person who works with him. 

b) To file the gap exception, you need to call Care Coordination at _________ insurance company. Here is the phone number to place that call. You will need to explain to them that you are the referring doctor, that there is no doctor in-network who can perform this procedure, and you may need to scan and/or fax them the Letter of Necessity as well. 

c) Here are the CPC codes for the procedure, whether the procedure is inpatient/ outpatient, the date the procedure is taking place, the time, and the name of the hospital where the procedure is taking place.  

d) Please be in touch with me if you need any more information. Here is my contact information.

5. Check in with the doctor to find out exactly when she has called in to start the Clinical Gap Exception process. They will give her a Reference Number. Call Care Coordination every day and ask them what the decision is on that reference number. If even one thing goes wrong (for instance, if your primary care physician incorrectly says that you are having an inpatient procedure instead of an outpatient one), they will shut the whole claim down and your doctor will need to start the whole process over again. So you want to make sure that you are on top of this. When a decision is made (to either approve or deny your request), make sure you get a letter from them in writing stating exactly what they are approving or denying.

Feel free to email me with questions about this process.